Thinking back to childhood, most of us have memories of the little hurts kids are prone to, and running to mom for a Band-aid and a kiss to make the hurt go away. But some hurts are beyond the soothing power of kisses. Serious injuries and health problems may require surgery and the full range of pain management a pediatric anesthesiologist can offer.
“The primary difference in anesthesia for adults and for children is that our patients come in all sizes, from tiny newborns to teens who may be larger than their parents,” Jennifer Dollar, MD, chief of Pediatrics Anesthesia Associates at Children’s Hospital of Alabama, said. “That means every anesthesia plan is unique. Dosages have to be individually calculated and every piece of equipment we use is selected for that particular patient’s size and weight.”
Size isn’t the only thing different in children. They aren’t just little adults. Children are more prone to conditions like asthma and more frequent colds that have to be taken into account when an anesthesiologist is planning the preparations they need to make before surgery.
“On the positive side, children are less likely to have issues like smoking, drinking and other lifestyle-related health problems that can complicate adult anesthesia,” Dollar said.
The challenge now in pediatric anesthesia is finding the right balance between two emerging topics of research. Recent studies suggest that childhood pain that isn’t adequately addressed can predispose a patient to a chronic pain syndrome in later life. On the other hand, research in young primates has raised the possibility that general anesthesia in patients under age four may affect neurological development, which could reduce the density of gray matter and may be associated with learning disorders, attention deficit and slower speech development.
“In every surgery and every anesthesia, we have to weigh the risks and benefits. We can’t allow children to suffer needlessly, and there are some surgeries that must be done very young, even for newborns, to protect their health and survival,” Dollar said. “However, if a surgery can wait till a child’s neurological development is farther along, that may be a consideration in timing the procedure.”
Whatever the age of the child undergoing surgery, Dollar focuses on keeping dosages as small as possible and the duration they are used as short as possible.
“We begin with a plan that uses a combination of strategies to keep the child comfortable. Going into surgery without their parents can be scary for a child. We talk with both the patient and the family so they know what to expect, and we discuss ways to make it easier for them,” Dollar said.
“In most surgeries, we use both inhaled anesthesia and IV anesthesia, along with a combination of other medications, all dosed by weight. If we are doing a procedure in an area that a block might be helpful in pain relief, such as a knee surgery, where a femoral nerve block can help control pain for 12 hours, we do the block then. This allows us to reduce the amount of medication needed after surgery to keep the patient comfortable.
“All through the procedure, we closely monitor blood pressure, heart rate, breathing and other indicators to make sure the patient isn’t in pain and that vital signs are optimum. Our recovery room nurses look for many of the same indicators to see that pain is being managed appropriately and that the patient is doing well.”
Outside the operating room, pain in children can be an issue pediatricians and family practice physicians have to deal with in their office--and in late night phone calls from frantic parents.
“If an infant too young to speak is crying inconsolably in its mother’s arms, if it’s drawing its legs up and crying, if it won’t eat, or if its heart rate and blood pressure are elevated, those are common indications of pain. Diagnosing the cause of the pain is the next step. If it’s something a pain reliever can help, I usually recommend an over the counter medication whenever possible, unless something stronger is necessary and if so, it should be closely monitored.
“Even with something like acetaminophen, there is a very narrow range of dosage that is safe. So teaching parents is essential. They need to be careful to make sure they are giving their child the right dose at the right time, and understand how important it is not to give the next dose too soon. Parents also need to look at any other medications the child is taking. Acetaminophen is often in cough syrups and even in prescription medications. Parents need to read every label to make sure their children aren’t getting a combined dose that could be dangerous.”
As children grow into teens, the questions an anesthesiologist asks in the pre-surgery conversation also change.
“We have to ask about smoking, drinking and possibly drugs that might interact with medications. If we suspect we may not be getting a straight answer when parents are around, we might have to ask the parents to step out or we may ask again later to see if we can get a more candid answer,” Dollar said.
During discharge planning, pain management is part of the teaching and after care instructions patients and their families receive.
Few of us get through life without pain. But with good pain management available at every age, there’s no need to hurt when you don’t have to.
